Surgical Considerations:
Cochlear Implantation in
Very Young Children
J. Thomas Roland, Jr., MD
Mendik Foundation Professor and Chairman
Otolaryngology-Head and Neck Surgery
Inspired by Parental Desire
IT-MAIS
120
100
80
Normal hearing
6m post-ci, n=18
12m post-ci, n=9
60
40
20
Pediatrics 2006
6m
7.
5m
10
m
13
m
17
m
26
m
3m
4.
5m
1m
2m
0
Implanting Under One
• Candidacy issues
– Certainty of testing and deafness
– Genetic evaluation
• Programming issues
– Objective programming
• Anesthetic Risks
• Surgical Risks
–
–
–
–
–
–
Blood volume concerns
Infectious risks
Scalp flap issues
Device migration
Skull shape and thickness
Facial nerve issues
Anesthetic Risks
• Pulmonary issues and cardiac reflexes to
volume changes and anesthetics
normalize around 6 months
• Risks are greatly reduced when a
pediatric anesthesiologist is present
Blood Volume
• Very young children do not have normal
cardiac reflexes related to blood loss
• Can lose 10% of volume without
significant consequences
• Ave. 11 lb (5kg) child has 350 cc volume
• Mastoids are not fully pneumatized,
mastoid emissary veins
– Use diamond burrs for parts of mastoid
– Careful on periostial elevation in pocket and behind mastoid
Infectious Risks
• Young children in general are at a higher risk
of meningitis
• The presence of a CI increases risks of
meningitis
• Kids with cochlear anomalies are at a higher
risk of meningitis
• Traumatizing the cochlear increases
meningitis risks
• Implanting earlier during the early otitis
media prone years may increase the risk as
well
• Bilateral ? Doubling the risk
Minimize Infectious Risks
• Immunizations are important (prevnar 13,
pneumovacs 23*)
• Treat OM early and aggressively,
communication with pediatricians
• Use of tympanostomy tubes is safe
• Minimal trauma to cochlea
• Effective atraumatic electrode design and
placement technique
• Peri-operative antibiotics
Scalp Flap and Fixation
• Drill large well and depress the device
with permanent fixation (this is
controversial)
– Minimizes migration
– Lowers profile and tension on thin scalp
• Concerns re: “tight pocket” concept
• Migration of R/S
Skull Growth Issues
• Migration of plates and closure of skull
sutures
Skull Growth Issues
• Cortex to Cochlea distance increases at
more rapid rate
6 months
48 months
Extrusions
• Will we see more electrode extrusions?
– Electrode fixation techniques
– Coiling electrodes grasp cochlea
• Consider extrusion when programming
issues arise
• Intra-operative baseline x-ray
Skull Shape Issues
• Placement usually more vertical in young
children
– Avoids coil on back of head
Facial Nerve
• Positioned close to surface until mastoid
tip develops
• Closer to surface within mastoid (1.0-1.5
cm)
Facial Nerve
• Use FN monitor
• Watch incision inferiorly near tip
• Avoid heating nerve when drilling
through facial recess
Summary
• With appropriate precautions and attention to
details, early implantation is safe
• Fixation is important
• Flap surveillance important
• Attention to placement on skull
• May need changes in device
– Even better electrodes
– Thinner Receiver/stimulators - smaller R/S
– External hardware modifications to accommodate skull
shape
Cochlear Implantation in the
very young child: long-term
safety and efficacy
Kevin H. Wang
J. Thomas Roland, Jr., Maura Cosetti,
Sara Immerman, Susan B. Waltzman
NYU School of Medicine
Laryngoscope 2010
comparison - complication rates
20%
18%
16%
14%
12%
10%
Minor
Major
8%
6%
4%
2%
0%
Present Study
(<12mo)
N = 50
Ovesen
(all ages)
Bhatia
(1-17yrs)
summary
• Complications for children <12mo. were
minimal
• No complications occurred after 10
months usage
• Pts with complications had excellent long
term outcomes
review of literature: CI<12 mo
1st Author
#
Peri-op Complications
James, AL
27
None
Colletti, V
10
None
Miyamoto, RT
13
None
Waltzman, SB
18
None
Dettman, SJ
19
None
Miyamoto, RT
8
None
Valencia, DM
15
One CSF leak
conclusions
• Cochlear implantation for children<12mo
is safe and effective, both short-term and
long-term
• Careful and continued monitoring is
necessary to minimize medical
complications
• 128 under one, 40% simultaneous
bilateral
Under One
Evidence
Safety and Efficacy
• Coletti (2)- N=13
– Outcomes from several indices (Category of
Auditory Performance, CAP; Peabody Picture
Vocabulary Test (Revised), PPVT-R; Test of
Reception of Grammar, TROG; and Speech
Intellegibility Rating, SIR) in three groups of
children with different ages at implantation
(from 4 to 36 months) with a follow-up time
from 4 to 9 years demonstrate that very early
cochlear implantation (<11 months) provides
normalization of audio-phonologic parameters
with no complications.
Safety and Efficacy
• Schawers, et al (Belgium) – N=10
– The earlier the implantation took place, the
smaller the delay was in comparison with
normally hearing children with regard to the
onset of prelexical babbling and with regard
to auditory performance as measured by CAP.
Safety and Efficacy
• Dettman et al- N=19
• Results demonstrated that cochlear implantation may
be performed safely in very young children with
excellent language outcomes. The mean rates of
receptive (1.12) and expressive (1.01) language
growth for children receiving implants before the age
of 12 mo were significantly greater than the rates
achieved by children receiving implants between 12
and 24 mo, and matched growth rates achieved by
normally hearing peers. These preliminary results
support the provision of cochlear implants for children
younger than 12 mo of age within experienced
pediatric implantation centers.
Safety and Efficacy
• Lesinski-Schiedat, et al – N=29
• This study revealed that children implanted
before the age of 1 year were subjected to no
additional risks and showed superior development
of speech understanding. Cochlear implantation
should therefore be performed in very young
children identified as suffering from profound
bilateral hearing loss. No anesthetic or surgical
complications.
Safety and Efficacy
• LOCHI Chin et al- N= 471 (41)
– When measured at 6 and 12 months and 3
years of age after implantation, children who
received CI prior to 12 months of age
developed language within normal levels, on
average Children who received CI after 12
months of age performed at 2 SD below the
mean.